Client is 8 weeks post motor vehicle accident (MVA) with diagnosed cervical strain (C5–C6) and lumbar strain (L4–L5). Currently in active treatment phase with chiropractic care 3×/week and monthly pain management follow-up.

Reports current pain level 7/10 with notable difficulty performing activities of daily living (ADLs), including prolonged sitting, lifting >10 lb, and overhead reaching. Sleep disrupted 3–4 nights per week. No new neurological symptoms; no bowel/bladder changes. Client is fully engaged with treatment plan and adherent to prescribed visits.

Clinical impression: musculoskeletal injury consistent with MVA mechanism; treatment trajectory appropriate; continued monitoring indicated.

• Highly compliant with treatment schedule; no missed appointments in past 4 weeks
• Strong family support system; spouse available for transportation and ADL assistance
• Motivated to return to work; employer supportive of modified duty when medically cleared
• Good health literacy; asks appropriate questions and follows home exercise instructions
• No substance abuse history; medication use as prescribed
• Previous positive response to conservative care for prior minor injury (2019)

• Transportation: Limited reliable transportation for 3×/week chiropractic visits; occasional reliance on family schedule
• Work schedule: Current work hours conflict with preferred therapy time slots; may need evening or early-morning options
• Insurance: Pre-authorization delays for physical therapy referral; PT start pending approval (estimated 1–2 weeks)
• Resources: Limited access to home exercise equipment; relying on bodyweight and resistance bands; ROM limited by pain
• Provider sequencing: Neurologist referral pending 3+ weeks; may affect documentation timeline if imaging or specialist opinion required

• Fall risk: Screen completed — no significant fall risk identified; home environment adequate
• Medication review: Current medications (NSAIDs, muscle relaxant PRN) reviewed; no significant interactions or contraindications
• Driving: Client advised to avoid driving when pain or medication affects alertness; limitations documented in plan
• Emergency contacts: Verified and on file; client knows to report any new weakness, numbness, or bowel/bladder changes
• Mental health: No acute safety concerns; client reports manageable anxiety regarding recovery timeline

Scores: 1 (critical) → 5 (optimal). Reassessment in 30 days or with significant change.

Based on intake, provider notes, and client report at time of assessment:

• Sitting: Tolerance ~30 minutes before pain increase; requires position change
• Standing/walking: Limited to ~20 minutes continuous; uses rest breaks for ADLs
• Lifting/carrying: Avoids >10 lb; reports increased pain with repetitive bending
• Overhead/reaching: Right shoulder and cervical motion limited by pain; left side less restricted
• Driving: Self-limited; avoids long distances; medication timing considered
• Sleep: Disrupted 3–4 nights/week; positional discomfort; next-day fatigue reported

Formal FCE not yet performed; above reflects clinical observations for care planning. Recommend re-evaluation at 12 weeks post-MVA or when treatment plateau is evident.

• Reduce pain level to ≤4/10 within 60 days with consistent treatment and home program
• Return to modified/light duty work within 30 days if medically appropriate and employer accommodation available
• Complete prescribed physical therapy regimen (once authorized) and maintain ≥90% attendance
• Improve 4Ps Physical and Professional scores by next reassessment (target: each ≥3)
• Establish sustainable home exercise routine; client independent with HEP by 45 days
• Maintain treatment compliance and documentation (diary, visits) to support recovery record

• Continue chiropractic care 3×/week per current plan; re-evaluate at 12 weeks
• Physical therapy: initiate once authorization received; focus on cervical/lumbar stabilization and graded activity
• Pain management: maintain monthly follow-up; medication review at each visit
• Home exercise program: education provided; progress to independent performance; document compliance
• Weekly Reconcile C.A.R.E. check-ins for first 4 weeks to monitor barriers and adherence
• Coordinate with attorney office for any records or work-status documentation requests

RN reassessment scheduled for February 15, 2025. Will evaluate treatment progress, 4Ps scores, functional capacity, and barrier resolution. Care plan will be updated as needed based on new documentation and client response.

Attorney will receive monthly summary report on the 1st of each month. Client reminded to maintain daily diary entries for optimal documentation. Next care plan review trigger: 30 days, or upon receipt of PT discharge summary / significant change in status.

Care plan valid until next RN review; any acute change in condition should be reported to treating providers and documented in Reconcile C.A.R.E. for attorney visibility.